Helicopter transport of patients to tertiary care centers after cardiac arrest

Appropriate Air Medical Services Utilization and Recommendations for Integration of Air Medical Services Resources into the EMS System of Care: A Joint Position Statement and Resource Document of NAEMSP, ACEP, and AMPA

Air medical services involves providing medical care in transit while using either fixed wing (airplane) or rotor wing (helicopter) aircraft to move patients between locations. The modern use and availability of air medical services has expanded access to various health system resources, including specialty care. While this is generally beneficial, such expansion has also contributed to the complexity of health care delivery systems.(1, 2) Since the publication of the 2013 joint position statement Appropriate and Safe Utilization of Helicopter Emergency Medical Services,(3) research has shown that patient benefit is gained from the clinical care capabilities of air medical services independent of potential time saved when transporting patients.(4-6) Because the evidence basis for utilization of air medical services continues to evolve, NAEMSP, ACEP, and AMPA believe that an update regarding the appropriate utilization of air medical services is warranted, and that such guidance for utilization can be divided into three major categories: clinical considerations, safety considerations, and system integration and quality assurance considerations.

Can a screening tool safely identify low risk cardiac patients to be transported with primary care flight paramedics?

OBJECTIVES

We aimed to determine the rate of adverse events during interfacility transport of cardiac patients identified as low risk by a consensus-derived screening tool and transported by primary care flight paramedics (PCP(f)).

METHODS

We conducted a health records review of adult patients diagnosed with a cardiac condition who were identified as low risk by the screening tool and transported by PCP(f). We excluded patients transported by an advanced care crew, those accompanied by a clinical escort from hospital, and those transported from a scene call, by rotary wing or ground vehicle. We recorded patient and transportation parameters using a piloted-standardized collection tool. We defined adverse events during transport a priori. We report descriptive statistics using mean (standard deviation), [range], (percentage).

RESULTS

We included 400 patients: mean age 66.9 years old, 66.5% male. Mean transport duration was 136.2 (74.9) minutes. Most common comorbidities were hypertension (50.3%) and coronary artery disease (39.5%). Most transports originated out of Northern Ontario and were for cardiac catheterization (61.8%) or coronary artery bypass grafting (26.8%). Overall, the adverse event rate was low (0.3%), with no serious event such as cardiac arrest, death, or airway intervention.

CONCLUSIONS

A screening tool can identify cardiac patients at low risk for clinical deterioration during air-medical transport. We believe patients screened with this tool can be transported safely by a PCP(f) crew, leading to potentially significant resource savings.

Polish Helicopter Emergency Medical Service (HEMS) Response to Out-of-Hospital Cardiac Arrest (OHCA): A Retrospective Study

BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a significant clinical challenge for emergency medical systems worldwide. The first step towards ensuring patient survival is achieving return of spontaneous circulation (ROSC). The purpose of the study was to analyze the cases of OHCA to which HEMS teams were dispatched. MATERIAL AND METHODS We performed a retrospective analysis of all HEMS calls in Poland for cases of OHCA between 1 January 2011 and 31 December 2016. Data were obtained from medical records maintained by the Polish HEMS. RESULTS The total number of responses to cases of OHCA was 2447. Of this total, 308 cases were excluded from the study as the patient was found not to have cardiac arrest or was confirmed dead. ROSC was achieved in 1119 cases, including 335 cases where ROSC occurred before the arrival of the HEMS team. In the group studied, ROSC was achieved more commonly in women, in patients younger than age 40 years, in CA cases of cardiac origin, and in cases with shockable rhythms (p<0.05). CONCLUSIONS The study results are consistent with global trends in terms of OHCA incidence and the effectiveness of CPR performed on scene. The study also demonstrates that HEMS dispatch to OHCA cases is justified both as a means of providing assistance to EMS teams on scene and as the first choice.

Cardiopulmonary Resuscitation Quality by Helicopter Rescue Swimmers While Flying

OBJECTIVE

Our objective was to assess the cardiopulmonary resuscitation (CPR) quality by helicopter rescue swimmers (HRSs) while flying.

METHODS

Twenty HRSs from the Spanish Maritime Safety took part in this study. The research protocol included 2 phases: a baseline test (5 minutes of CPR on land) and a challenge test (5 minutes of CPR on a Sikorsky S-61N helicopter in-flight). A Laerdal Resusci Anne mannequin with Laerdal PC Skill Reporting (Stavanger, Norway) was used to register CPR variables.

RESULTS

CPR quality on land versus in-flight was not significantly different. The mean chest compression (CC) depth (52.6 mm on land vs. 51.9 mm in-flight) was inside the recommended range, but mean CC rate (133 vs. 132 per minute), tidal volume (752 vs. 888 mL), and hands-off time (9 per cycle in both tests) were above the 2015 recommended goal. Incomplete chest re-expansion was observed in 19% of on land and 26% in-flight CCs. CPR quality was maintained throughout the 5-minute challenges.

CONCLUSION

HRSs are able to perform CPR in a flying helicopter with similar quality to CPR on land. They need additional training to avoid excessive CC rates, tidal volumes, and hands-off times and to permit chest re-expansion.

Medical Emergency Workload of a Regional UK HEMS Service

OBJECTIVE

Regionalized trauma networks have been established in England to centralize specialist care at dedicated centers of excellence throughout the country. Helicopter emergency medical services (HEMS) in the West Midlands region have been redesigned to form an integrated component of such systems. The continued use of such valuable and scarce resources for medical emergencies requires evaluation.

METHODS

A retrospective review of mission data for a regional Air Ambulance Service in England over a two year period.

RESULTS

Medical emergencies continue to contribute a large proportion of the overall workload of the service. Requirement for advanced interventions at the scene was rare, with less than 10% of patients attended by HEMS teams having care needs that fall beyond the scope of standard paramedic practice.

CONCLUSION

Dynamic solutions are needed to ensure that HEMS support for cases of medical emergency are appropriately targeted to incidents in which clinical benefit is conferred to the patient. Intelligent tasking of appropriate resources has the potential to improve the HEMS response to medical emergencies while optimizing the availability of resources to respond to other incidents, most notably cases of major trauma.

Characteristics of nontrauma scene flights for air medical transport

INTRODUCTION

Little is known about the use of air medical transport for patients with medical, rather than traumatic, emergencies. This study describes the practices of air transport programs, with respect to nontrauma scene responses, in several areas throughout the United States and Canada.

METHODS

A descriptive, retrospective study was conducted of all nontrauma scene flights from 2008 and 2009. Flight information and patient demographic data were collected from 5 air transport programs. Descriptive statistics were used to examine indications for transport, Glasgow Coma Scale Scores, and loaded miles traveled.

RESULTS

A total of 1,785 nontrauma scene flights were evaluated. The percentage of scene flights contributed by nontraumatic emergencies varied between programs, ranging from 0% to 44.3%. The most common indication for transport was cardiac, nonST-segment elevation myocardial infarction (22.9%). Cardiac arrest was the indication for transport in 2.5% of flights. One air transport program reported a high percentage (49.4) of neurologic, stroke, flights.

CONCLUSION

The use of air transport for nontraumatic emergencies varied considerably between various air transport programs and regions. More research is needed to evaluate which nontraumatic emergencies benefit from air transport. National guidelines regarding the use of air transport for nontraumatic emergencies are needed.

A blueprint for critical care transport research

INTRODUCTION

An estimated 500,000 critical care patient transports occur annually in the United States. Little research exists to inform optimal practices, promote safety, or encourage responsible, cost-effective use of this resource. Previous efforts to develop a research agenda have not yielded significant progress in producing much-needed scientific study.

PURPOSE

Identify and characterize areas of research needed to direct the development of evidence-based guidelines

METHODS

The study used a modified Delphi technique to develop a concept map of the research domains in critical care transport. Proprietary, internet-based software was used for both data collection and analysis. The study was conducted in 3 phases: brainstorming, categorizing, and prioritizing, using experts from all aspects of critical care transport.

RESULTS

A total of 101 research questions were developed and ranked by 27 participants representing the transport community and stakeholders. An 8-cluster solution was developed with multidimensional scaling and hierarchical cluster analysis to identify the following research areas: clinical care, education/training, finance, human factors, patient outcomes, safety, team configuration, and utilization. A plot characterized each domain by urgency and feasibility.

CONCLUSION

The content and concepts represented by the cluster map can help direct research planning in the critical care transport industry and prioritize funding decisions.

Brain resuscitation in the drowning victim

Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.

Helicopter emergency medical services (HEMS) response to out-of-hospital cardiac arrest

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) is a common medical emergency with significant mortality and significant neurological morbidity. Helicopter emergency medical services (HEMS) may be tasked to OHCA. We sought to assess the impact of tasking a HEMS service to OHCA and characterise the nature of these calls.

METHOD

Retrospective case review of all HEMS calls to Surrey and Sussex Air Ambulance, United Kingdom, over a 1-year period (1/9/2010-1/9/2011). All missions to cases of suspected OHCA, of presumed medical origin, were reviewed systematically.

RESULTS

HEMS was activated 89 times to suspected OHCA. This represented 11% of the total HEMS missions. In 23 cases HEMS was stood-down en-route and in 2 cases the patient had not suffered an OHCA on arrival of HEMS. 25 patients achieved return-of-spontaneous circulation (ROSC), 13 (52%) prior to HEMS arrival. The HEMS team were never first on-scene. The median time from first collapse to HEMS arrival was 31 minutes (IQR 22-40). The median time from HEMS activation to arrival on scene was 17 minutes (IQR 11.5-21). 19 patients underwent pre-hospital anaesthesia, 5 patients had electrical or chemical cardioversion and 19 patients had therapeutic hypothermia initiated by HEMS. Only 1 post-OHCA patient was transported to hospital by air. The survival to discharge rate was 6.3%.

CONCLUSION

OHCA represents a significant proportion of HEMS call outs. HEMS most commonly attend post-ROSC OHCA patients and interventions, including pre-hospital anaesthesia and therapeutic hypothermia should be targeted to this phase. HEMS are rarely first on-scene and should only be tasked as a first response to OHCA in remote locations. HEMS may be most appropriately utilised in OHCA by only attending the scene if a patient achieves ROSC.

Severity of cardiovascular disease patients transported by air ambulance

INTRODUCTION

Although helicopters have been used in an air ambulance system for the past decade in Japan, the appropriate selection of patients for this transport mode has not been investigated. The present study investigates which patients could potentially benefit the most from helicopter emergency medical service (HEMS).

METHODS

We investigated the extent of circulatory and respiratory support required in the intensive care unit (ICU) and ultimate outcomes of 2340 patients with cardiovascular disease admitted to 1 institution between October 2001 and December 2009. Two hundred and seventy were transported by HEMS (HEMS group), and 2070 were transported by other means (non-HEMS group).

RESULTS

Temporary cardiac pacing, ventilator management, intra-aortic balloon pumping, percutaneous cardiopulmonary support, electrical defibrillation, and therapeutic hypothermia were more frequently required by patients in the HEMS group vs. the non-HEMS group (10.4%, 28.1%, 17.0%, 5.2%, 10.0% and 3.4% vs. 8%, 17.9%, 10.9%, 2.3%, 4.5% and 0.4%, respectively). The mortality rate was higher in the HEMS group than in the non-HEMS group in the ICU (9.6% vs. 5.3%).

CONCLUSION

Disease was more clinically severe and the outcome was poorer among patients with cardiovascular diseases transported by HEMS than by other means.

What risk managers should know about air medical patient transport

The use of air medical services (AMS) has become an essential component of the healthcare system. Appropriately used air medical critical care transport can save lives and reduce the cost of healthcare. It does so by minimizing the time the critically ill and injured spend out of a hospital, by bringing more medical capabilities to the patient than are normally provided by ground emergency medical services, and by helping get the patient to the appropriate specialty care quickly. Risk managers should be aware of the everyday decisions made in critical care transport to ensure the most appropriate utilization of resources to benefit the patient.

Use of an air ambulance system improves time to treatment of patients with acute myocardial infarction

OBJECTIVE

The aim of this study was to clarify whether a helicopter ambulance system (doctor helicopter system; DHS) could shorten the time interval to coronary intervention in the treatment of patients with acute myocardial infarction (AMI), in comparison with ground ambulance (GA).

METHODS

The time from the emergency call to coronary angiography (CAG time) or to percutaneous coronary intervention (PCI time), and the inhospital outcome were evaluated in 76 AMI patients. Twenty patients were transported by DHS, and the other 56 were by GA.

RESULTS

Both CAG time and PCI time were significantly shorter in the DHS (98.8+/-29.2 min, and 169.6+/-57.4 min) than those of the GA (126.6+/-48.7 min, and 203.2+/-57.0 min; p<0.05) group. Inhospital mortality was lower in the DHS (5.0%) versus the GA (10.7%) group.

CONCLUSION

Use of DHS shortened the time interval to coronary intervention and also improved the inhospital prognosis of AMI patients.

Regionalization of Treatment for Subarachnoid Hemorrhage

BACKGROUND

Previous studies have shown that for the treatment of subarachnoid hemorrhage (SAH), outcomes are improved but costs are higher at hospitals with a high volume of admissions for SAH. Whether regionalization of care for SAH is cost-effective is unknown.

METHODS AND RESULTS

In a cost-utility analysis, health outcomes for patients with SAH were modeled for 2 scenarios: 1 representing the current practice in California in which most patients with SAH are treated at the closest hospital and 1 representing the regionalization of care in which patients at hospitals with <20 SAH admissions annually (low volume) would be transferred to hospitals with > or =20 SAH admissions annually (high volume). Using a Markov model, we compared net quality-adjusted life-years (QALYs) and cost per QALY. Inputs were chosen from the literature and derived from a cohort study in California. Transferring a patient with SAH from a low- to a high-volume hospital would result in a gain of 1.60 QALYs at a cost of 10,548 dollars/QALY. For transfer to result in only borderline cost-effectiveness (50,000 dollars/QALY), differences in case fatality rates between low- and high-volume hospitals would have to be one fifth as large (2.2%) or risk of death during transfer would have to be 5 times greater (9.8%) than estimated in the base case.

CONCLUSIONS

Transfer of patients with SAH from low- to high-volume hospitals appears to be cost-effective, and regionalization of care may be justified. However, current estimates of the impact of hospital volume on outcome require confirmation in more detailed cohort studies.

Guidelines for the inter- and intrahospital transport of critically ill patients*

OBJECTIVE

The development of practice guidelines for the conduct of intra- and interhospital transport of the critically ill patient.

DATA SOURCE

Expert opinion and a search of Index Medicus from January 1986 through October 2001 provided the basis for these guidelines. A task force of experts in the field of patient transport provided personal experience and expert opinion.

STUDY SELECTION AND DATA EXTRACTION

Several prospective and clinical outcome studies were found. However, much of the published data comes from retrospective reviews and anecdotal reports. Experience and consensus opinion form the basis of much of these guidelines.

RESULTS OF DATA SYNTHESIS

Each hospital should have a formalized plan for intra- and interhospital transport that addresses a) pretransport coordination and communication; b) transport personnel; c) transport equipment; d) monitoring during transport; and e) documentation. The transport plan should be developed by a multidisciplinary team and should be evaluated and refined regularly using a standard quality improvement process.

CONCLUSION

The transport of critically ill patients carries inherent risks. These guidelines promote measures to ensure safe patient transport. Although both intra- and interhospital transport must comply with regulations, we believe that patient safety is enhanced during transport by establishing an organized, efficient process supported by appropriate equipment and personnel.

[Critical care helicopter transport. Report of 224 cases]

OBJECTIVE

To report a 5-year experience of pediatric helicopter transport and describe its characteristics, the composition of the team, its indications and the advantages of air versus ground transport.

METHODS

A total of 224 flights over a 5-year period were retrospectively analyzed. The team was composed of a pediatrician and a pediatric nurse from the Pediatric Department of Hospital Sant Pau and was available 365 days per year from sunrise to sunset. The helicopters belonged to the Royal Automobile Club of Catalonia and were coordinated by the Emergency Medical Service. The area covered was Catalonia and Andorra. The number of patients, age, sex, diagnosis, and response and stabilization times were recorded.

RESULTS

There were 220 patients (139 males and 81 females). Six patients died in the primary hospital before transport. Seven flights were canceled because of adverse weather, engine breakdown, or family refusal. Three twin transportations were performed. A total of 214 patients were transported in 224 flights. The mean times (in minutes) were: from emergency call to takeoff: 15; flight time: 39; between landing to the emergency room: 10. The mean stabilization time was 42 min.

CONCLUSIONS

Helicopter transportation of critically-ill children by specialist teams of pediatricians and nurses shortens response time in isolated areas with poor transport. The lower number of accelerations and vibrations of the helicopter provides greater stability during transport, especially in trauma patients. Both transport models, air and ground, should be complementary.

Drowning

Recent epidemiologic data have shown that the burden of drowning is much greater than expected. Prevention and timely rescue are the most effective means of reducing the number of persons at risk. Early bystander cardiopulmonary resuscitation is the most important factor for survival after submersion. Cerebral damage is a serious threat when the hypoxic period is too long. In most situations, low body temperature is an indication of the severity of the drowning incident. Sometimes hypothermia that occurs during the submersion period can be brain protective. There is also new evidence to support the strategy of inducing mild hypothermia for a period of 12 to 24 hours in comatose drowning victims. In immersed patients, hypothermia should be treated. The most appropriate technique will depend on the available means in the hospital and the condition of the patient. Treatment of pulmonary complications depends on the lung injury that occurred during aspiration and the bacteria involved in aspiration. Understanding the pathophysiology of drowning may help us to understand lung injuries and ischemic brain injuries.

When is dead, dead? The ethics of resuscitation in emergency care

Each year thousands of people suffer a cardiac arrest. Technology, care provider education, and emergency services access have made it possible to successfully resuscitate many patients. The outcome however, may not always be positive for the patient or their family. This article looks at the ethics of resuscitation and how to determine when to start and stop resuscitation so that patients, families, and emergency care providers may make informed and acceptable decisions related to resuscitation and its potential outcomes.